Postpartum Family Planning: What to Expect When Youre No Longer Expecting...

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Postpartum Family Planning What to Expect When
Youre No Longer Expecting...

• Holly Blanchard Angela Nash-Mercado
• 12 September 2008

Jhpiego in partnership with Save the Children,
Constella Futures, The Academy for Educational
Development, The American College of
Nurse-Midwives and IMA World Health
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Session Objectives

• By the end of the session participants will be
  able to
• Discuss the rationale for family planning during
  the extended postpartum period
• Explain benefits of healthy pregnancy spacing
• Describe return to fertility for postpartum women
  both lactating and non-lactating
• Describe contraceptive methods appropriate for
  lactating women
• Describe programmatic considerations related to
  PPFP pre-discharge counseling
• Describe programmatic considerations for
  postpartum long-acting and permanent methods

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(No Transcript)
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Source FHI 2000
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How can postpartum family planning save infants
lives?
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Analysis of postpartum family planning needs in
Kenya
Source ACCESS-FP DHS reanalysis on postpartum
women in Kenya, 2006
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What are the postpartum family planning needs of
Kenyan women?
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Factors that influence fertility Nigeria
Triangle of Exposure
Insert Text for Question Category 1 50 points
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• What are the factors that influence return to
  fertility?

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(No Transcript)
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What are Postpartum Contraceptive Options and
Timeline?
Adapted from the MAQ Exchange Contraceptive
Technology Update
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Bangladesh Birth-to-birth Intervals
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What is the graphic representation of birth
spacing among women in Bangladesh? (Note
women who space births apart)
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• The recommended interval before attempting the
  next pregnancy after a live birth, is at least 24
  months.
• This interval reduces the risk of adverse
• Maternal
• Perinatal and
• Infant outcomes

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• What is the recommendation from the expert
  committee to WHO on birth spacing (2005)?

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• This interval is consistent with the WHO and
  UNICEF recommendation on breastfeeding
• AND
• This interval is associated with the lowest risk
  of adverse maternal, perinatal and infant outcome
  

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• What is the birth-to- pregnancy interval of at
  least 24 months?

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Women who conceive within 6 months of delivering
their last infant are 7.5 times more likely to
terminate the pregnancy (and to be at risk for an
unsafe abortion)
DeVanzo 2007
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• What are the odds that a woman will terminate a
  pregnancy if conceived too soon?

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Prematurity Fetal death Low birth weight Small
for gestational age Neonatal and infant mortality
Conde-Agudelo (2006) Rutstein (2005)
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• What are the perinatal and infant risks when
  birth to pregnancy spacing is less than 24
  months?

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• 1 million of the 11 million deaths in children
  
  intervals of less than 2 years. Effective use of
  postpartum family planning is the most obvious
  way in which progress should be achieved.
• (Cleland 2006)

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• What is one of the benefits of postpartum family
  planning in regards to averting mortality?

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• Return to sexual activity
• Reduction in breastfeeding
• Resumption of menses

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• What are the behaviors and characteristics that
  increase the postpartum womans risk for an
  unintended pregnancy?

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For fully lactating, amenorrheic mothers with
infants less than 6 months--
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• What is the risk of pregnancy for women
  practicing LAM?

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In some countries, it is common for women to
practice postpartum abstinence while
breastfeeding.
Degrées-du-Loû, A and Brou, H.  (2005).
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• What is a traditional practice that may affect
  perception of pregnancy risk in the extended
  postpartum period?

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The risk of pregnancy occurs prior to onset of
menses. According to studies 6-10 of women may
conceive prior to menses returning.
Becker Ahmed, 2001
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• What is the percentage of women who conceive
  prior to menses return?

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• A study that provides insight into when ovulation
  and the required hormonal levels are right to
  support fertility which occurs-as early as 30-37
  days post delivery in non-breastfeeding women

Gray, R.H., Campbell, O.M., Apelo, R., Eslami,
S.S., Zacur, H., Ramos, R.M., et al. (1990.)
Risk of ovulation during lactation. The Lancet,
335(8680) 25-29.
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• When is a non-breastfeeding postpartum woman
  potentially at risk for an unintended pregnancy?

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• Revitalization of lactational amenorrheic method
  of contraception (LAM) and transition to other
  modern methods increased contraceptive uptake in
  nine facilities in Ouagadougou.

ACCESS-FP and IRH 2007
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• What are the benefits of LAM revitalization
  particularly transition to other modern methods?
• LAM is a GATEWAY to other methods

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• LAM,
• Progestin-only methods (POP, DMPA, Noristerate,
  implants)
• IUDs and
• Sterilization

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• What are contraceptive methods that breastfeeding
  women can initiate before 6 months?

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• Non-breastfeeding women can start progestin-only
  methods when they are discharged from the
  facility or within the first few days postpartum.
  
• They can start combined oral contraception at 3
  weeks postpartum

WHO MEC 2004
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• When can non-breastfeeding women start hormonal
  contraception?

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• HIV-positive women, who are unable to use
  supplemental feeding because it is not
  acceptable, feasible affordable, safe and
  sustainable, may use this method of contraception
  and their infants will have increased chances of
  survival.

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• What is LAM?

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• While the repeat DMPA injection can be given up
  to 4 weeks late without requiring additional
  contraceptive protection, this does not mean that
  the regular DMPA injection interval can be
  extended by 4 weeks.

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• What is the newest recommendation by WHO MEC
  regarding the grace period for women late for
  their next DMPA?

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• When FP materials were provided on the postpartum
  ward in Pakistan
• significantly increased client uptake of modern
  contraceptive methods controlled by women.
• When these materials were not available
• clients more likely to be using traditional
  methods controlled by men.

Saeed (2008)
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• What can the systematic provision of PPFP
  materials do to influence uptake of modern
  contraception?

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Benefits Risks

• Post-insertion symptoms are masked by the normal
  postpartum cramping and lochia
• Cost-effective for the client and facility
• Client leaves the facility with an effective
  method
• Training provides a review to providers on IP,
  counseling and AMTSL
• Insertion is done when there is no risk of
  pregnancy

• Increased risk for spontaneous expulsion
• Risk of poor counseling
• Need to initiate counseling in ANC

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• What are some of the risks and benefits of
  providing postpartum IUDs (within 48 hours)?

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Vernon R, et al 2008
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• How does the timing of information on
  contraception affect the probability of
  postpartum women initiating contraception in the
  Dominican Republic?

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Unmet Need 1st Year Postpartum and All Women
Category 5 40 points
Source Borda, M. and W. Winfrey. Family
Planning Needs during the First Year Postpartum.
ACCESS-FP.
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• How does unmet need among postpartum women
  compare to that of all women?

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Mexico 2006 Current Contraceptive users
according to the time that they started the
method
Vernon et al. 2008
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• What is the impact of offering LAPMs to
  postpartum women?

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Summary and Reference Slides
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Rationale for family planning during the extended
postpartum period

• Postpartum women express a desire to prevent
  pregnancy during first two years after delivery
  but the majority are not using contraception
  (UNMET NEED)
• Antenatal, postnatal and immunization visits are
  opportunities for PPFP messages to women who
  accessing health facilities multiple times

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Benefits of PPFP

• 9-10 Reduction in infant mortality rate
• Reduction in exposure to unsafe abortion
  (responsible for 13 of MMR)
• Family planning in general can reduce MMR by 32

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Return to fertility

• Fertility returns prior to onset of menses
• 6-10 conceive prior to menses.
• Fully lactating amenorrheic mothers of infants
  less than 6 months ---

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Contraceptive methods for lactating women

• Progestin-only methodsupdates from WHO
• LAM, transition, and AFASS
• PPIUCD
• sterilization

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Programmatic implications related to PPFP
pre-discharge counseling

• Systematic provision of PPFP at time of discharge
• Counseling and information can increase
  contraceptive use
• LAM is a gateway method to other family planning
• Increase in contraceptive methods (method mix)
  increases uptake and effective use

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Rationale for long-acting and permanent methods

• Demand for limiting among postpartum women
• At time of delivery opportune moment
• ANC counseling!

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Photo by A. Nash-Mercado
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Resource list

• Marston C, Cleland J (2004) The effects of
  contraception on obstetric outcomes WHO Library
  Cataloguing-in-Publication
• Cleland, J., Bernstein, S., Ezeh, A., Faundes,
  A., Glasier, A., Innis, J. (2006.) Family
  planning The unfinished agenda. The Lancet,
  368(9549), 1810-1827.
• Ross, J. A. and Winfrey, W. L. (2001.)
  Contraceptive use, intention to use and unmet
  needs during the extended postpartum period.
  International Family Planning Perspectives, 27,
  2027.
• Ross, J Winfrey W (2002) Unmet Need for
  Contraception in the Developing World and the
  Former Soviet Union An Updated Estimate
  International Family Planning Perspectives,
  28(3)138143
• DaVanzo J, L Hale, A Razzaque, M Rahman (2006)
  Effects of interpregnancy interval and outcome of
  the preceding pregnancy on pregnancy outcomes in
  Matlab, Bangladesh www.blackwellpublishing.com/bjo
  g
• Senarath, U., Fernando, D.N., and Rodrigo, I.
  (2006.) Factors determining client satisfaction
  with hospital-based perinatal care in Sri Lanka.
  Tropical Medicine and International Health,
  11(9), 1442-1451.
• Gulshan Ara Saeeda,?, Shazia Fakhara, Faisal
  Rahimb, Sabir Tabassum (2008) Change in trend of
  contraceptive uptakeeffect of educational
  leaflets and counseling, Contraception
• Gray, R.H., Campbell, O.M., Apelo, R., Eslami,
  S.S., Zacur, H., Ramos, R.M., et al. (1990.)
  Risk of ovulation during lactation. The Lancet,
  335(8680) 25-29.
• Khalaf, I.A., Abu-Moghli, F.A., Mahadeen, A.I.,
  Callister, L.C., and AlHadidi, M. (2007.)
  Jordanian womens perceptions of post-partum
  health care. International Nursing Review,
  54(3), 288-294.
• Vikhlyaeva, E., Nikolaeva, E., and
  Brandrup-Lukanow, A. (2001.) Contraceptive use
  and family planning after labor in the European
  part of the Russian Federation 2-year
  monitoring. European Journal of Contraception and
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• Hight-Laukaran, V., Labbok, M. H., Peterson, A.
  E., Fletcher, V., von Hertzen, H., and Van Look,
  P. F. (1997.) Multicenter study of the
  Lactational Amenorrhea Method (LAM) II.
  Acceptability, utility, and policy implications.
  Contraception, 55(6), 337346.
• Hardy, E., Santos, L. C., Osis, M. J., Carvalho,
  G., Cecatti, J. G., and Faundes, A. (1998.)
  Contraceptive use and pregnancy before and after
  introducing lactational amenorrhea (LAM) in a
  postpartum program. Advances in Contraception,
  14(1), 5968.
• Lopez-Martinez, M.G., Romero-Gutierrez, G.,
  Ponce-Ponce De Leon, A.L. (2006.) Acceptance of
  lactational amenorrhoea for family planning after
  postpartum counseling. The European Journal of
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  11(4), 297-301.
• Jansen, W.H. (2005). Existing demand for birth
  spacing in developing countries Perspectives
  from household survey data. International
  Journal of Gynecology and Obstetrics, 89 (Suppl
  1), 550-560.
• Norton, M. (2005.) New evidence on birth
  spacing Promising findings for improving
  newborn, infant, child, and maternal health.
  International Journal of Gynecology and
  Obstetrics, 89 1-6.
• Report of a WHO Technical Consultation on Birth
  Spacing Geneva, Switzerland, 1315 June 2005
• Eroglu K., Akkuzu, G., Vural, G., Dilbaz, B.,
  Akin, A., Taskin, L., et al. (2006.) Comparison
  of efficacy and complications of IUD insertion in
  immediate postplacental/early postpartum period
  with interval period 1 year follow-up.
  Contraception, 74(5), 376-381
• Grimes, D., Schulz, K., Van Vliet, H., and
  Stanwood, N. (2003.) Immediate post-partum
  insertion of intrauterine devices. The Cochrane
  Database of Systematic Reviews, Issue 1. Art.
  No CD003036. DOI 10.1002/14651858.CD003036.